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Prior notification and utilization management
BCBSM uses the following pre-approval programs to help ensure appropriate and cost-effective care. The process helps identify cases that may benefit from the assistance of one of our care management programs.
We strongly recommend that you use InterQual® criteria for preadmission notification and precertification.
Preadmission notification
For continuity of care, hospitals, including hospitals with swing beds, are required to notify us when admitting a Medicare Plus Blue PPOSM member using web-DENIS for preadmission notification.
Precertification
To make sure that the member is receiving the most appropriate care in the most appropriate setting, the following facilities are required to precertify services before admitting a Medicare Plus Blue PPO member:
- Skilled nursing facilities
- Inpatient rehabilitation hospitals, both freestanding rehabilitation hospitals and rehabilitation units within acute care hospitals
- Long-term acute care hospitals
Beginning July 14, 2011 all facilities must submit precertification requests via fax to 1-866-464-8223 or via e-fax to MedicarePlusBlueFacilityFax@bcbsm.com. For information about the precertification fax process, access these helpful Fax Process FAQ (PDF). Use the appropriate form below to submit your request.
Michigan MA PPO
- Michigan MA PPO long-term acute care hospital e-fax assessment form (PDF)
- Michigan MA PPO skilled nursing facility e-fax assessment form (PDF)
UAW Retiree Trust
- Long-term acute care hospital e-fax assessment form (PDF)
- Skilled nursing facility e-fax assessment form (PDF)
- Acute inpatient e-fax assessment form (PDF)
All fields on the assessment form must be completed upon submission to ensure timely and efficient processing. Incomplete forms will be returned to the originating facility for completion.
Before you contact us
The proposed service must be a benefit under the patient's active contract. Check your patient's BCBSM coverage by using the web-DENIS or CAREN to verify the benefit before you fax or email your precertification request.
Preauthorization for the AIM Radiology Management Program
AIM Specialty Health preauthorizes high technology services (PDF) for BCBSM's Medicare Advantage PPO radiology management program.
Without approved preauthorization, claims will be denied and you may not bill the member.
We encourage providers to access AIM's website before scheduling to ensure the high technology service meets our criteria.
Providers should request preauthorization through AIM's website or by calling 1-800-728-8008. Note: Effective Jan. 1, 2012, AIM no longer supports order entry requests via fax. All requests submitted on or after Jan. 1, 2012, should be submitted online through AIM's ProviderPortalSM or via telephone.
Please Note: The program applies only to BCBSM Medicare Advantage PPO members receiving services from contracted providers. Non-BCBSM Medicare Advantage PPO members, non-contracted providers emergency room, observation room, inpatient services and secondary coordination of benefits are not included in this program.
Behavioral Health Services
The Behavioral Health Management program works with members and providers to coordinate mental health and substance abuse services for Medicare Plus Blue PPO individual and group members. Services include:
- 24/7 availability of case managers
- Comprehensive discharge planning
- Post discharge care coordination
All mental health and substance abuse inpatient, partial hospital and intensive outpatient admissions or extensions require prior authorization and concurrent review. Acute care hospitals and behavioral health facilities that need to arrange an inpatient admission, partial hospital admission, intensive outpatient admission or concurrent review for behavioral health services must obtain prior authorization by phone at 1-888-803-4960 or via fax to 1-866-315-0442.
Learn more about care management.
